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Nonanatomic, sublobar “wedge” resection of lung cancer is generally considered a “compromise” pulmonary resection for primary treatment of lung cancer directed to the physiologically impaired patient who is at high risk for lobectomy.1,2 This assessment of the clinical utility of wedge resection is being challenged, particularly for the management of the small peripheral lung cancer where a generous wedge resection can be accomplished with acceptable surgical margins.
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The goal of sublobar resection is lung parenchymal preservation, and as with the use of segmental breast-preserving resection of small breast cancers, limitation in the ability to control the tumor locally is appreciated as an important potential drawback. As with breast cancer, surgical margin status is at the heart of the matter of local recurrence. Regional lymph node status and histologic, molecular, and biologic findings suggestive of an aggressive tumor, such as angiolymphatic invasion, visceral pleural invasion, and gene mutational findings appear to be independent predictors of survival from the “resection marginal” status of surgery.
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Nevertheless, local recurrence following lung cancer resection is an important problem leading to potential patient morbidities (i.e., bronchial obstruction, chest wall invasion, pleural effusion). Intraoperative measures to avoid local recurrence, such as enhancing surgical margins of resection and the use of intraoperative radiobrachytherapy at the margin of surgical resection, have been explored.3–5 Postoperative radiotherapy directed to the staple line margins of resection has also been explored in the past.6
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In this chapter, we review the basic strategies for successful open thoracotomy and VATS wedge resection of peripheral small lung malignancies (i.e., peripheral small primary lung cancer and pulmonary metastasis from remote primary cancers). We also direct attention to the primary uses of wedge resection for the diagnosis of suspicious pulmonary lesions suspected to be malignant (i.e., the indeterminate pulmonary nodule). The outcomes reported in the literature for wedge resection of these pathologic conditions will be reviewed.
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Primary Pulmonary Lesions Amenable tO Sublobar (Wedge) Resection
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The primary principles for selection of sublobar resection for pulmonary pathologic lesions are noted in Table 77-1. The lesion should be in the outer third of the lung parenchyma and less than 3 cm in diameter, as more deeply seated and larger lesions will require broader resections toward the base of the lobar hilum which may compromise margins of resection or result in loss of the physiologic integrity of the remaining lobe (Fig. 77-1).7–10 Similarly, if an endobronchial extension of the tumor is identified by bronchoscopic examination, wedge resection with adequate surgical margins is impossible. Upon these basic tenets rest the utility of wedge resection for the management of pulmonary parenchymal lesions, specifically the use of wedge resection for the treatment of lung cancer. Of course, the use of laser or electrocautery precision excision of deeper pulmonary lesions may make possible the resection of small, ...